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18 December 1959 



NavMed 369 



Vol. 34, No. 12 




UNITED STATES NAVY 



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"Fur it is in giving - . , thot we receive" 
From Ihe prayer of St. Francis of AssiH 




To OUT Medical Department family and friends^ it is 
my privilege and pleasure to say again, "Well Done! And moy 
you hove a Holy Christmas and a Happy New Year." 

In the yeor just passed^ we hove continued to do 
our part hefping to bring the gift of health to those who defend 
the nation, and fo their families. Their need has been 
our primary concern, and their welfare conKnues uppermost 
in our thoughts ond all that we do. 

In the spirit of this Holy Season, I send you 
greetings and ask that you join me in a simple prayei" that we 
may give unstlntingly of ourselves and of our 
copabilities to the men and women of the Navy and Morine 
Corps and thus to the service of our God and our Country. 



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2 Medical News Letter, Vol. 34, No. 12 

TABLE OF CONTENTS 

ABSTRACTS 

Changing Views on Heart Failure 3 

Diffuse Myocardial Fibrosis 5 

Radioiodine in Treatment of Hyperthyroidism 6 

Roentgenographic Findings in Complications of Diabetes Mellitus 7 

Rehabilitation of the Bladder in Injuries of the Spinal Cord 10 

Postoperative Nasal Gastric Suction ..., 12 

Carcinoma of Corpus Uteri 13 

MISCELLANEOUS 

Vaccine for Trachoma Developed at NAMRU-2, Taipei 15 

Navy Mutual Aid Terminal Dividend now $2000 16 

A Letter to the Surgeon General 17 

Military Immunization - New Film Release 18 

Directives 18 

Use of Flammable Anesthetics (BuMed Inst. 5100. IB) 
Dependents' Care Outside U.S. {BuMed Inst. 6320. 22A) 

Recent Research Reports 19 

From the Note Book 21 

DENTAL SECTION 

Twelfth Anniversary of Dental Rating 24 

Reduced Lactobacilli Count Due to Elimination of Caries .........,,.., 25 

The Nature of Discipline 25 

Continuous Training Program 27 

Newly Standardized Dental Item 27 

Professional Meetings 28 

Obituary 28 

RESERVE SECTION 

Criteria for Earning Pronaotion Point Credits 29 

AVIATION MEDICINE SECTION 

Flight Fatigue 32 

Flight Physical Examinations 38 

SPECIAL NOTICE 39 



Medical News Letter, Vol. 34, No. 12 3 

Changing Views on Heart Failure 

The total picture of cardiac failure, with consequent dyspnea and edema 
as major manifestations, is one of considerable complexity. Accurate methods 
of cardiac output determination put an end to many speculative hypotheses. 
When the organism requires a high output, as in anoxic and anemic states, 
the overworked heart may go into failure. The switch of emphasis from output 
to work enables appreciation that every failing heart is an overloaded heart. 
The overload may result from narrowed or inconapetent valves, elevated pres- 
sure head in the systemic or pulmonary arteries, or inadequate muscle re- 
duced either in its anatomic bulk by ischemic scarring or more subtly dam- 
aged by rheumatic inflammation. 

These factors will affect the heart at rest, but what happens on exercise 
must be considered when additional stimuli whip the heart to greater effort. 
The pump is driven at an increased rate, it ejects more blood at each beat, 
possibly responding to increased secretion of adrenalin. These mechanisms 
tend to supersede and obscure the simple working of Starling's law in normal 
animals and man. In the diseased or embarrassed heart, excessive tachy- 
cardia develops with relatively minor activity, but it is in the later stages 
that the heart loses its flexibility, the resting rate in failure with sinus rhy- 
thm settles to around 90 to 100 per minute, and the heart ceases to respond 
to the other finely adjusted physiologic mechanisms. At this stage, an 
elevated venous pressure may make its appearance. 

Starling demonstrated a steadily rising cardiac output response as the 
venous filling pressure was elevated, but this response flattened out and a 
falling output reaction developed as the filling pressure was raised beyond 
a certain limit. It is this descending limb of the Starling curve which seems 
to correlate so closely with many observations in human heart failure. 

Facts which have been demonstrated in man include: 

1. Rapid transfusion in the anemic heart will precipitate failure. 

2. Exercise will often elevate venous pressure, but output of the 
heart may actually fall. 

3. Venesection frequently increases cardiac output. 

4. Mercurial diuretics, by decreasing blood volume, lower venous 
pressure and often increase cardiac output. 

5. Physical rest has the converse effect of exercise, dropping venous 
pressure and increasing output. 

6. Output of the heart in hypertensive failure will increase when venous 
pressure and arterial resistance are reduced by hypotensive drugs. 

It bears emphasizing that diuresis is a potent method of reducing venous 
pressure with corresponding hernodynamic improvement. The rapid loss of 
fluid by the kidney depletes the vascular fluid compartment substantially — an 
effect comparable to venesection. 

Formerly, it was imagined that the falling psirt of the Starling curve was in 
some way related to overstretching of myocardial fibers. Quick recovery which 



4 Medical News Letter, Vol. 34, No. I?. 



Gould take place during venesection led to the conclusion that the damage was 
not irreparable, and that it was more likely to be mechanical than due to any 
profound metabolic breakdown. 

A major part of therapeutic effort in heart disease consists of attempts 
to remove the extra load imposed on the heart. In addition to such medical 
measures as digitalis, rest, diuretics, and reduced sodium intake, the sur- 
geon can aid by breaking adherent valves. Crude though his methods may be, 
the surgeon gives promise of more profitable results as the techniques for 
open heart surgery are improved. Nevertheless, the bulk of heart disease 
will long remain strictly in the realm of the physician. 

Improvements in management of bronchitis, asthma, emphysema, hyper- 
tension, and other conditions imposing an extra load on the heart will add to 
the increasing success in treatment of heart failure. 

Dynamics of early left ventricular strain are matters of great moment. 
One interesting manifestation is the development of an auricular gallop sound. 
This sound is related to the end of inflow from the atrium into the ventricle, 
and its presence means that auricular filling is terminated; the resulting 
sound is created either by distention of the ventricular wall or by an upward 
movement of the mitral valve cusps. Taking the load off the left ventricle 
will cause regression of this sound with a migration to the first sound before 
fusion with that sound. 

These phenomena, together with appearance of an atrial sound, in 
ischemic heart disease indicate the importance of this physical sign in judging 
the imnainence of more severe failure. A full appreciation of its meaning will 
add greatly to the understanding of that condition. 

The mode of action of digitalis is still perplexing. Its action is most 
often demonstrable in left ventricular failure, particularly in hypertensive or 
ischemic heart disease. It is almost impossible to predict the metabolic state 
of the heart on which digitalis may exercise its action. Every time it is given, 
its administration is something of an experiment. 

Recently, it has been shown that during attacks of anginal pain, pulmon- 
ary vascular pressures are usually elevated. Relief of angina by nitroglycerin 
is accompanied by corresponding relief of pulmonary hypertension. Thus, that 
left ventricular failure is a common accompaniment of anginal pain is apparent. 
It is worthwhile to find out if shortness of breath is a component of anginal dis- 
comfort. Where it is present, digitalis administration may be of value in 
reducing frequency of attacks. 

Progress in understanding the behavior of the failing heart is being made, 
and efforts in treatment have become more logical. (McMichael, J. , Changing 
Views on Heart Failure: Ann. Int. Med., 5_1^: 635-640, October 1959) 

sjc 4: 4c :«: 1^ 4: 

Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget (19 June 1958). 



Medical News Letter, Vol, 34, No. 12 



Diffuse Myocardial Fibrosis 

Myocardial fibrosis is defined as a diffuse replacement or invasion of 
the myocardium by fibrous connective tissue to such an extent that there is 
interference with the action of the heart. It may be expected that the nature, 
location, and extent of such fibrosis will influence its manifestations in a 
given patient. Probably the most frequent cause is coronary artery disease, 
but many other diseases, diffusely involving the myocardium, also can 
result in myocardial fibrosis. 

Approximately Z5 years ago, chronic myocarditis or myocardosis was 
a popular and frequent diagnosis. It was defined as a lesion in which cardiac 
failure was associated with normal valves and pericardium while the heart 
muscle showed hypertrophy alone or in combination with fibrous interstitial 
myocarditis. Subsequent work established that most of these patients had 
either hypertensive or coronary artery disease as a cause of their cardiac 
failure. 

The authors' study of 14 patients having myocardial fibrosis which pre- 
sents symptoms suggesting constrictive pericarditis, defines features of 
differential diagnosis. 

In general, these patients with diffuse myocardial disease and without 
pericardial disease presented themselves with the manifestations of intract- 
able heart failure. There was usually a definite onset in time. No patient 
had clear evidence of valvular disease or hypertension. Phenomena usually 
observed were: (1) elevated venous pressure, (2) congestive hepatomegaly, 
(3) ascites, (4) peripheral edema, (5) cardiomegaly, (6) distant heart sounds, 
(7) diastolic gallop, (8) dirriinished fluoroscopic cardiac pulsations, (9) signs 
of peripheral congestion more pronounced than those of pulmonary congestion, 
(10) ECG with low voltage and nonspecific T-wave changes, and (11) disappoint- 
ing response to usual treatment for congestive heart failure. 

One of the most characteristic findings in patients with diffuse fibrosis 
or constrictive pericarditis is an intractable course resistant to treatment. 
Nothing about the course can serve to differentiate one fronm the other. 

History of an original injury to either pericardium or myocardium — 
acute pericarditis or myocardial infarction — may be significant. The weight 
one gives to this evidence depends on thoroughness of documentation. 

Pulsus paradoxus may occur in both conditions, but in the experience of 
the authors, it has been more frequent and impressive in patients with con- 
strictive pericarditis. 

Characteristic calcification involving the pericardium, usually present 
in some 50% of patients with constrictive pericarditis, is evidence in favor of 
that disease, although its absence is not conclusive. Furthermore, intravas- 
cular pressures are not specifically diagnostic. 

It is apparent that neither physical findings, course, nor catheterization 
measurements permit differentiation between myocardial fibrosis and peri- 
cardial constriction. Because these disorders affect cardiac hemodynamics in an 



Medical News Letter, Vol. 34, No. 12 



identical fashion, it is to be expected that their signs and symptoms should 
be virtually identical. In many patients, this difficult differential diagnosis 
can only be resolved by direct inspection of the heart. (Burwell, C. S. , 
Robin, E. D. , Diagnosis of Diffuse Myocardial Fibrosis; Circulation, XX : 
606-614, October 1959) 

Radioiodine in Treatment of Hyperthyroidism 

The authors add experience gained from 294 patients to that accumulating 
in medical literature in relation to treatment of hyperthyroidism with radio- 
active iodine. Details of diagnosis and treatment of these patients over a 
7-year period is included. 

The oldest patient was 78; the youngest, 16; and 86 patients, or 29%, 
were below the age of 40. The authors consider that the early fear that cancer 
might be produced by radiation from P^l ji^^^g ^ot materialized, and that one 
must weigh the theoretical risk inherent in the use of ionizing radiation against 
the risk of any other modality of treatment. To date, no authentic instance of 
thyroid cancer developing as a result of I^ ■ ^ therapy for hyperthyroidism has 
been published. The incidence of leukemia has been shown to be no greater 
than in the general population. Furthermore, the comparatively tiny dose of 
radiation received from blood-borne 1^^^ following therapy of hyperthyroidism 
apparently exerts no deleterious effect of gene mutation of gonads. 

Ninety-five patients presented thyroid glands that were not palpably en- 
larged. Diffuse goiter was seen in 193; nodular toxic goiter was present in 71 
patients. No previous antithyroid treatment had been given to 176 while propyl- 
thiouracil had been given in varying doses and for periods up to 2 years to 43 
patients. 

Diffuse toxic thyroid was made to regress with relatively small doses of 
radioiodine, and approximately two-thirds of the total cases were controlled 
by a single dose. Two-thirds of the remaining cases were controlled by a 
second dose; two-thirds of this remainder needed a third dose; and two-thirds 
of this remainder needed one more dose. In other words, a patient stood a 2: 1 
chance of being controlled by any individual dose, with diffuse goiters doing 
somewhat better than nodular. It is interesting to note that 88% of all patients 
with diffuse and nodular enlargement were controlled by one or two doses. 
The experience of the authors corroborates experience of others that 
improvement, if it occurs, is often quickly evident. In 63%, a positive response, 
judged by clinical signs and symptoms and by ll 31 uptake and saliva count, was 
already evident by the end of the third month after the therapeutic dose. The 
patient who manifested slow improvement was watched for a period up to 6 
months before a second therapeutic dose was given. However, if toxicity was 
still severe at the end of 3 months, additional therapy was considered. 



Medical News Letter, Vol, 34, No. 12 



The patients followed in this series maintained remissions for periods 
up to 7 years. The toxic thyroid patient controlled for one year rarely showed 
recrudescence. 

In this study, 81 cases of exophthalnaos of various grades of severity 
were noted with improvement in 48%, no change in 50%, and moderate aggra- 
vation in 2%. To date, initial appearance of exophthalmos after a maintained 
remission has not been observed. 

End results indicate clinical remission in 93% of whom 85% were made 
euthyroid and 8% hypothyroid. In successful therapy of hyperthyroidism with 
I , as with surgery, a certain percentage of hypothyroidism is inevitable. 
The 24 patients who became hypothyroid were, therefore, included as successes. 

In a group of 80 patients given strong iodine solution beginning 24 hours 
after treatment dose of radioiodine, the half-life of radioactive material and 
ultimate clinical response were not altered, compared to those not receiving it. 

The change in size of the enlarged thyroid gland parallels clinical res- 
ponse. Many nodular goiters will completely regress, although some residual 
nodularity is a more common result. 

Eighteen patients developed hypothyroidism within one year and 6 devel- 
oped it subsequently. To date, no patient has become hypothyroid after 3 years 
of remission. No correlation was found between the induction of hypothyroidism 
and dose range or age of the patient. 

Four patients experienced transient thyroiditis inanifested by pain and 
tenderness over the thyroid gland and slight fever within 2 weeks after admin- 
istration of the radioiodine. One case of thyroid crisis with ensuing death 
occurred in a severely toxic girl 16 years of age. {Rubenfeld, S. , et al. , 
Radioiodine in the Treatment of Hyperthyroidism - A Seven-Year Evaluation: 
A.M. A. Arch. Int. Med., 104: 532-538, October 1959) 

****** 

Roentgenographic Findings in 
Connplications of Diabetes Mellitus 

Few diseases definitely associated with one organ and one metabolic 
function have such widespread concomitant pathologic changes as does diabetes 
mellitus. The protean nature of this disorder has been appreciated clinically 
for many years and there have been many reports in radiologic literature con- 
cerning particular aspects of these pathologic changes. Certain roentgen 
changes are almost pathognomonic and other changes occur with such frequency 
as to be highly suggestive of the disease. 

Of 672 cases of diabetes mellitus occurring over a 3-year period, 177 
patients were examined roentgenographically with a total of 547 different 
examinations. From these examinations, roentgenographically evident 
lesions encountered in diabetes mellitus were obtained. 



Medical News Letter, Vol, 34 , No. 12 



Genitourinary System . Necrotizing renal papillitis is found only in 
cases of diabetes mellitus or in obstructive uropathy with secondary infection. 
Therefore, in the absence of the latter, its presence should suggest the diag- 
nosis of diabetes mellitus. This process goes through various stages with the 
end result of club-like fossa and, sometimes, incrustation by calcium salts. 

Gas -forming infection in the perirenal tissues is the next common com- 
plication. Escherichia coli is nearly always the causative agent. Multiple 
small bubbles of gas in the perirenal area are quite characteristic in appear- 
ance. Gas-forming infections of the bladder are also a fairly frequent occur- 
rence. Cystitis ennphysematosa is recognized by a halo of gas about the 
bladder shadow. The condition almost invariably occurs in diabetics, but may 
be transient and thereby go undetected. The blebs are recognizable on cysto- 
scopic examination as well as roentgenographically. Primary pneumaturia is 
also found, but usually as a complication of neurogenic bladder secondary to 
diabetic neuropathy. In these cases, examination for urine sugar may be 
negative due to utilization of the sugar by bacteria. 

Diabetes mellitus may sometimes be the underlying disease in neuro- 
genic bladder dysfunction — so-called "cord bladder " — manifested roentgeno- 
graphically by a large bladder size and reflux of opaque material into the 
ureters which are also large in caliber. Calcification of the vas deferens and 
seminal vesicles has been described on the basis of pathologic observations, 
but this finding was not encountered roentgenographically in the present series 
of cases. 

Adenocarcinoma of the corpus uteri raay also be related to diabetes mel- 
litus in that its frequency of occurrence is increased. This complication may 
prove of concern to the radiologist as a therapeutic problem. 

Gastrointestinal System . In review of 7Z cases of diabetes mellitus 
with dysphagia, 10 examples of ripple esophagus were found. A neuromuscular 
dysfunction found most frequently in elderly people, this condition may repre- 
sent nerve degeneration in a diabetic. When encountered in a relatively young 
person, the possibility of diabetes mellitus as a cause for the dysfunction 
should be considered. 

Acute dilatation of the stomach is a frequent finding in diabetic acidosis. 
The dilatation promptly returns to normal with control of the diabetes. Diar- 
rhea, likewise, occurs frequently in diabetics, being due to hypermotility of 
the small intestine. 

Of diabetic abnormalities of the pancreas which may produce roentgen 
findings, pancreatitis, either acute or chronic, is most common. In the acute 
stage there may be evidence of multiple small bubbles of gas in the region of 
the pancreas — almost invariably a complication of diabetes mellitus. The 
calcific stage of pancreatitis may also be evident roentgenographically. Cysts 
or pseudocysts of the pancreas may be associated with diabetes and may be 
another manifestation of chronic pancreatitis. It is of interest that the inci- 
dence of carcinoma of the pancreas is strikingly increased in diabetes mellitus. 



Medical News Letter, Vol. 34, No. 12 



Gas infection, of the gallbladder is occasionally noted in diabetes mellitus. 
The infection may cause emphysematous changes in the wall of the gallbladder 
or may fill the gallbladder itself with gas. The subject of incidence of chole- 
lithiasis and cholesterosis has been debated at great length, with no specific 
conclusions, and study of the present series resulted in no definite opinions 
or findings. 

Skeletal System . Changes in the skeletal systena secondary to diabetes 
mellitus are ascribed to three causes — neuropathy, avascular necrosis, and 
osteoinyelitis. Diabetic Charcot joints, identical with that of Charcot joints 
of other etiology, exhibit fragmentation, eburnation, absorption of articular 
surfaces, loose bodies in the joint, and calcific deposits in the synovial mem- 
brane. The ankle is the nnost frequently involved joint, with tarsal and meta- 
tarsal articulations being the second nnost frequently involved sites. 

A far more frequent occurrence is presence of avascular necrosis. The 
earliest roentgenographic finding in this condition is demineralization of a 
spotty variety, frequently followed by resorption of the tufted end of the term- 
inal phalanges. At the stage of resorption of bone, frank gangrene is present 
in soft tissues. Osteomyelitis which follows is frequently accompanied by a 
gas -forming infection in adjacent soft tissues. 

Nervous System . Probably the most common abnormality of the nervous 
system in diabetes mellitus is the so-called diabetic neuropathy. The theory 
of etiology with the most proponents is that it is due to arteriosclerotic changes 
in the vasa nervorum. Roentgenographic findings are dependent upon which 
organ is supplied by the affected nerve. Charcot joints, tabes diabetica, func- 
tional abnormalities of the esophagus, and cord bladder are some of the mani- 
festations of neuropathy that are evident roentgenographically as abnormalities 
of the organ supplied by the affected nerve. Nonspecific changes in various 
organs should be kept in mind, recognizing diabetes mellitus as a possible 
etiologic agent. 

Acromegaly, a disease due to eosinophilic adenoma of the pituitary in 
which diabetes mellitus is sometimes found, exhibits characteristic roentgeno- 
graphic changes. 

Cardiovascular Systena . Pathologically, arteriosclerotic changes ob- 
served in diabetes are not characteristic of the disease. However, it has been 
noted that intimal thickening and deposition of cholesterol crystals sire found 
in elastic vessels and that calcification of the media is seen primarily in mus- 
cular vessels. It is a fairly frequent occurrence to observe in the 30 to 50 -year 
age group extensive calcification of the vessels of the feet with little or no cal- 
cific deposits in the aorta. Extensive calcification of pedal vessels is seldom 
observed in diseases other than diabetes nnellitus in patients under 50 years 
of age. 

Skin. There may be amorphous deposits of calcium in the skin and sub- 
cutaneous tissue .in cases of diabetes mellitus, although they were not recognized 
in the present series. 



10 Medical News Letter, Vol. 34, No. 12 



Lung s . Two pulmonary abnormalities are encountered in diabetes 
mellitus with increased frequency — hyaline membrane disease and pulnaonary 
tuberculosis. The former occurs in 16% of infants of diabetic mothers; the 
latter has been occurring with decreasing incidence, although the decrease 
has not been as rapid as the decrease of tuberculosis in the general population. 

Diabetes mellitus is not often regarded as a disease which requires 
roentgenographic confirmation. Its complications, however, can frequently 
be diagnosed by roentgenologic means, {Beck, R. E. , Roentgenographic 
Findings in the Complications of Diabetes Mellitus: Am. J. Roentgenol. , 
82: 887-896, November 1959) 

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Rehabilitation of the Bladder in 
Injuries of the Spinal Cord 

In the hours immediately following trauma to the spinal cord the phys- 
ician works energetically to save life. The tremendous disturbance of the 
patient's central nervous system necessitates that energetic care continue 
beyond the immediate life-saving stage. Of all problems that exist, care of 
the urinary system is one of the most important. 

In one instance, review of autopsy findings of paralysis patients re- 
vealed that renal disease was the most common primary pathologic diagnosis, 
while genitourinary disease was present in 90%, Better renal function had 
occurred in the absence of catheter drainage. 

In treating the paraplegic patient, the ultimate goal is to obtain as soon 
as possible a functioning bladder characterized by: (1) catheter-free existence, 
(2) adequate capacity with negligible residual urine, (3) socially acceptable 
urination, and (4) absence of infection. 

In order to approach the problem of bladder rehabilitation logically, 
knowledge of the neurogenic mechanisms of the bladder is required, review 
of which is presented by the authors. After analysis of the neurologic deficit, 
specific corrective procedures may be employed to facilitate establishment of 
acceptable bladder function. 

Care of the genitourinary tract begins on the first day of admission. 
Dangers of inadequate care are emphasized to the patient — his cooperation is 
essential. A fluid intake of 240 ml. (full glass) every hour from morning 
until bedtime is established immediately to provide an intake of at least 
3,000 nnl. daily. The indwelling catheter is attached to continuous drainage, 
and the bladder is irrigated four times a day with sterile saline. To avoid 
distention, continuous drainage is nnaintained during the so-called atonic 
phase when detrusor contraction is absent. 

When detrusor activity appears, tidal irrigation, catheter clamping, 
or both, may supplant continuous drainage in selected patients. If a patient 



Medical News Letter, Vol. 34, No. 12 11 



is awetre of vesical contractions and can immediately institute drainage, the 
urethral catheter may be clamped. Tidal drainage is effective as an irrigator 
and in increasing the capacity of the small irritable spastic bladder. 

Excretory urography and retrograde cystourethrography are done early 
and repeated as necessary. Cystoscopic examination together with other uro- 
logical procedures are performed as indicated. 

Return of detrusor activity is determined by retrograde cystometry. 
This is performed every 3 to 4 weeks until detrusor activity is apparent. 
When it returns, the catheter is removed. If a high residual urine is present, 
catheter drainage is reinstituted and additional voiding trials are made at two- 
week intervals. If detrusor activity is adequate but voiding is not, sphinctero- 
metry may be useful. 

After the catheter is removed, the patient voids at scheduled times. The 
schedule is subsequently adjusted to correspond with rate of urine production 
while still maintaining high fluid intake. Capacity is best determined from 
amounts voided plus residual rather than by retrograde filling. 

Infection appears rapidly after initial catheterization and urine rarely 
becomes sterile even after the patient becomes catheter-free. Long-term 
antibacterial medication is indicated to control infection. The broad spectrum 
antibiotics are usually reserved for acute febrile urinary infections. 

In order to reduce incidence of calcvdi, this regimen is followed: (1) fluid 
intake of at least 3,000 ml. daily, (2) maintenance of acidity of urine, (3) cath- 
eter changes weekly or oftener if encrustation occurs^ (4) elimination of milk 
from diet, (5) aluminum gel (30 ml. ) 4 tinaes a day — with naeals and at bed- 
time — to reduce phosphaturia, and (6) oral administration of salicylates be- 
cause they are excreted as glucuronide complexes which increase the solubility 
of calcium salts. 

How long to wait for adequate reflex elimination to develop before inter- 
vening is a difficult question, A fair standard is either 6 months after injury, 
or 2 to 4 months after appearance of detrusor contraction, whichever occurs 
later. 

Within the frannework of a small hospital center with frequently chang- 
ing staff, the author developed the outlined schedule of rehabilitation. Of 59 
patients undergoing this rehabilitation, 64% became catheter-free. Men did 
slightly better than women; and patients with autonomous bladders had a 
greater conversion rate than did those with reflex bladders. The average 
length of time after injury for the patients to become catheter -free was seven 
and one -half months. Patients with upper motor neuron lesions converted in 
6 months and those with incomplete lesions in 3 months. Ischemic ulcer was 
the major cause of failure to attain a catheter-free status and vesical lithiasis 
was the most frequent urinary tract complication. 

Although adequate function may develop in the cord bladder, there is no 
guarantee that it will continue; therefore, protracted follow-up is essential. 
Renal lesions, especially calculi, may occur in spite of adequate drainage or 



12 Medical News Letter, Vol. 34, No. 12 



physiologic emptying of the bladder. Important as are the first 6 months 
after injury, long-term care is equally necessary if morbidity and early 
death from renal disease are to be avoided, {Stolov, W. C. , Rehabilitation 
of the Bladder in Injuries of the Spinal Cord: Arch. Phys. Med. , 40: 467- 
474, November 1959) ~ 

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Postoperative Nasal Gastric Suction 

Gastric suction has been of tremendous benefit in treatment of certain 
gastrointestinal diseases. This fact has led to its widespread utilization, 
especially postoperatively during the period of relative ileus. However, 
reports have indicated that serious complications can occur fronn the pres- 
ence of an indwelling gastric catheter, and that after an uncomplicated laparo- 
tomy, routine insertion of a xiasal-gastric tube is inadvisable. This conclusion 
is based on the fact that a relatively small amoiint of gastric fluid withdrawn 
through an indwelling tube can be readily absorbed by the postoperative gut 
even in the presence of ileus, and air ingestion is minimal if fluids are withheld. 

A fasting volume of saliva and gastric fluid is continually secreted, the 
average quantity of each being about 1 liter, with wide variations. In the normal 
fasting state this fluid is passed readily and immediately into the small bowel 
where it is reabsorbed. An indwelling gastric tube is able to capture only a 
portion of this fluid as it passes through the stomach. 

The amount of air swallowed in the fasting state and during fluid intake has 
not been determined. Observations of the authors indicate that little air is swal- 
lowed in a fasting state, but that with ingestion of liquids, swallowed air is great 
er in quantity than the fluid intake regardless of the manner of taking the fluids. 

Two small groups of patients were studied. One group was intubated, and 
fluids were restricted; the other group was also intubated and water intake was 
allowed and encouraged. When oral intake was withheld, drainage amounted 
to approximately 600 ml. of gastric fluid and 2,000 ml. of air in each 24 hours. 
Quantitative determinations of sodium content of the aspirated fluid revealed 
that an average of 42 mEq. was lost each 24 hours. Average chloride content 
each 24 hours was 70 mEq. Total electrolyte losses were not of a large mag- 
nitude and would be replaceable by an infusion of approximately 500 ml. of 
physiologic saline. 

In the group that received oral fluids, total fluid aspiration indicated 
mininnal stimiilation of gastrointestinal secretion by fluid ingestion. Electrolyte 
loss was increased somewhat — particularly sodium — although the total loss 
was insignificant. The volume of air trapped was considerably greater in the 
group allowed fluids, averaging 1.3 ml. of air recovered for each ml. of water 
taken. These findings demonstrate vividly that air ingestion is a major factor 
when large volumes of fluid are allowed. 



Medical News Letter, Vol. 34, No. 12 13 



Although the need for gastrointestinal decompression is the primary 
consideration in tube usage, it is not the only one. Considerable discomfort 
accompanies maintenance of gastric intubation. Approximately 75% of patients 
studied by the authors had distress from the tube, and sore throat and thirst 
paralleled in intensity tube discomfort. There was no significant difference 
in thirst and tube discomfort when comparing patients on fluid intake with 
those receiving nothing by mouth. Sore throat was significantly more frequent 
in the fasting group, probably a reflection of the constant dryness of the oral 
and pharyngeal mucosa. Despite tube insertion, 45% had some nausea, and 
20% vomited while the tube was in place. 

While conditions are not completely comparable with nonintubated 
patients, it appears that the average person taking no fluids postoperatively 
swallows approximately 2 liters of recoverable air and accumulates in the 
stomach about 600 rnl. of recoverable salivary and intestinal secretion each 
day. With increasing oral intake, considerable air and fluid can be accumu- 
lated. Somewhere, a point of decompensation is reached, dependent on the 
degree of ileus present. However, the additional liter of fluid and air accunciu- 
lated by the drinking of 400 ml. of water would probably cause no severe dis- 
tress, while the water intake would improve nriorale and tend to prevent sore- 
ness and dryness of the throat. 

The unintubated postlaparotomy patient taking small amounts of fluid by 
mouth will have less fluid and electrolyte loss, less chance of respiratory 
infection or other tube complications, be more comfortable, and be more 
easily ambulated. (Mehnert, J.H. , et al. , A Clinical Evaluation of Post- 
operative Nasal Gastric Suction: Surg. Gynec. & Obst. , 109: 607-612, 
November 1959) 

Carcinoma of Corpus Uteri 

Carcinoma arising- in the endometrium is the second nnost frequent 
malignant tumor to develop within the genital organs of women. There is 
mounting evidence that there is an absolute increase in the incidence of 
neoplasm of the corpus uteri. An investigation in Stockholm of the cause of 
postmenopausal vaginal bleeding indicates that 6 out of 10 patients who consult 
a doctor because of spontaneous bleeding 2 years or more after the menopause 
have a malignant tumor of the pelvis. In the years 1948 through 1951, the 
author saw 617 patients with prinaary carcinoma of the endometrium. 

In spite of these facts, delay in diagnosis of the carcinoma is formidable. 
In propaganda for early diagnosis, teaching of physicians is still important. 

Carcinoma of the corpus is often accompanied by degenerative cardio- 
vascular disease, essential hypertension, obesity, diabetes, and/or other 
endocrine abnormalities. These and other facts justify the suggestion that 



14 Medical News Letter, Vol. 34, No. 12 



endocrine factors play a part in pathogenesis of endometrial carcinoma. 
Other features of pathogenesis of this carcinoma are variable and uncertain 
with many proposed theories. 

Primary carcinomas of the corpus are generally adenocarcinomas. 
In the author's experience, a pure solid carcinoma was encountered infre- 
quently, and mixed tumors were rare. 

In general, curettage is required to establish the diagnosis. An endo- 
metrial biopsy is of value in the early diagnosis as it can be performed on 
an ambulatory basis. The diagnosis of an adenocarcinoma from curettings 
is sometimes difficult. Prior to administration of therapy, information 
must be obtained on the extent of the carcinoma to the isthnaus and cervix. 
In most instances, a fractional curettage facilitates the estimation of the 
extension of the carcinoma. 

Sometimes, clinical examination or differential curettage does not give 
sufficient information regarding the location of the carcinoma. If so, hys- 
teroscopy or hysteroradiographic examination with water-soluble contrast 
medium is imperative prior to any kind of therapy. Some authorities have 
stressed the value of the x-ray examination prior to curettage in every 
instance of postmenopausal hemorrhage. The author does not like to do it 
routinely because he considers that it may increase the risk of infection and 
spread of the cancer. Special x-ray studies, such as arteriography or veno- 
graphy, or parametriography are of value in selected cases of carcinonaa 
of the endometrium associated with another growth in the pelvis. 

Present international clinical classification recommends division of 
carcinoma of the endometrium into carcinoma of the corpus, and carcinoma 
of the corpus and endocervix. A subgrouping of the carcinonma into two stages 
with regard to clinical findings prior to treatment is recommended. Because 
carcinoma of the corpus frequently occurs in patients with severe cardiovas- 
cular disease or obesity, it has been recommended that Stage I be separated 
into two groups — those clinically operable and those clinically inoperable. 
The need for this subdivision depends on the skill and experience of the opera- 
tor and the surgical team available. 

Types of treatment are total hysterectomy by the abdominal or vaginal 
route, radical hysterectomy, radiotherapy, or a combination of radiotherapy 
and operation. Radical hysterectomy with lymphadenectomy only may be the 
treatnrxent of choice in cases of carcinoma of the endometrium with extension 
to the isthmus or cervix. The author advocates use of radium as a prophylactic 
postoperative procedure, and enaploys irradiation more generally than most clinics. 

The "packing" technique employed since 1936 is described. The principle 
is to fill the uterine cavity satisfactorily with radium tubes and thus decrease 
the distance from radium to neoplasm. Recently, in addition to irradiation pat- 
ients of good operative risk are referred to surgery 6 weeks after completion of 
radiotherapy. (Kottmeier, H. L,. , Carcinoma of the Corpus Uteri -Diagnosis and 
Therapy: Am. J. Obst. & Gynec. , 78: 1127-1140, November 1959) 



Medical News Letter, Vol. 34, No. 12 15 



Vaccine for Trachoma 



Developed at NAMRU-2, Taipei 

A United States Navy medical research unit in the Republic of China, 
working with Chinese physicians, has developed a vaccine which may play 
a significant role in halting spread of trachoma, an infectious eye disease 
affecting more than 400 million people. 

This announcement was made recently in Washington, D. C, and in 
Taipei, Taiwan by RADM Bartholomew W. Hogan, Surgeon General of the 
Navy, and Dr. J. Thomas Grayston, Assistant Professor of Medicine at 
the University of Chicago, who is now on the staff of Naval Medical Research 
Unit No. 2 in Taipei. 

Dr. Grayston told the story of a year's work by three American and 
two Chinese physicians at the annual meeting of the Formosan Medical 
Association in Taipei. The Chinese physicians are Y. F. Yang, Professor 
of Ophthalmology at the National Taiwan University College of Medicine in 
Taipei, and S. P. Wang of Taipei, a mennber of the U. S. Navy medical 
research unit staff. The American physicians — R. L. Woolridge of Lake 
Bluff, 111. , and P.B. Johnston of Chicago — are attached to the unit command- 
ed by CAPT R.A. Phillips MC USN. 

The group has successfully isolated several strains of trachoma virus, 
reproduced the disease in human, beings, and developed a vaccine safe for 
human use. Scientists previously had isolated the trachoma virus in other 
countries, but there have been no other reports on a successful vaccine. 
Dr. Grayston was reluctant to make predictions as to the ultimate success 
of the vaccine. He did admit, however, that tests conducted to date were 
encouraging and that the trachoma vaccine had tremendous potential as a 
preventive and possibly a curative measure of the illness which often results 
in total blindness. 

The medical unit's studies began in October 1958. The first step was 
to isolate trachoma virus. By cultures in chicken egg embryos at the NAMRU 
laboratories, Dr. Wang ultimately isolated five viruses thought to be the 
cause of trachoma. The next step was to determine if these virus strains 
would reproduce trachoma. Initial experiments with monkeys produced an 
infection which resembled the early stages of the human disease, but did not 
progress to formation of scar tissue. Because the World Health Organization's 
expert comnnittee on trachoma requires that a virus must reproduce trachonna 
in human volunteers before it can be accepted as the cause of the disease, it 
was necessary to obtain volunteers for subsequent tests. 

Realizing the potential importance of the tests, six students and one 
instructor of the Taipei Blind and Mute School volxinteered for the next phase 
of the studies. Four volunteers were given trachoma virus in various dilutions, 
and three received control material. The virus, even when diluted 10,000 times, 
promptly produced infection in the human eye. None of the controls contracted 
the disease. 



16 Medical News Letter, Vol. 34, No. 12 



Dr. Woolridge, an immunologist, immediately attempted preparation of 
an effective vaccine, using nnonkeys as test animals. Several vaccines were 
prepared which produced increase in antibody titer to the parent virus strain 
and protected the monkeys against infection. The investigators gave the 
vaccines to themselves and demonstrated that side reactions were no more 
severe than from commonly used vaccines. 

In order to test the effectiveness of the vaccine, volunteers were needed 
once again. The entire freshmen class at the National Defense Medical College 
at Taipei — 150 students — responded to the need. All ultimately received two 
doses of the vaccine without adverse reaction. These studies demonstrated 
that the vaccine produces antibodies against the virus, an encouraging finding 
since the natural disease produces antibodies only irregularly. 

Moving still farther afield, the group is now studying the protective and 
curative value of the vaccine in 450 children. Although early observations 
are highly promising, Dr, Grayston stated that at least another year will be 
required before the tests can be completely evaluated. 

The importance of the NAMRU studies was emphasized by a world health 
authority who said recently, "Should these tests prove successful, and the vac- 
cine now being used found capable of preventing the disease and curing young 
persons afflicted with it, one of the foremost achievements in the medical his- 
tory of the world will have been recorded, " 

Navy Mutual Aid Terminal Dividend Now $2000 

The Board of Directors of Navy Mutual Aid Association on 24 November 
1959 voted to pay a $2, 000 terminal dividend to the designated beneficiary of 
any member whose death shall occur after 1200 EST on 24 November 1959. 
This dividend is payable on a member's death in cash or as annuity. Total 
death benefit is now $9,500. Paid-up mentiberships of less than $7, 500, term- 
inated by death, will be increased by 26 and 2/3%. This dividend does not in- 
crease loan or surrender values of memberships. 

This action by the Board of Directors is the fourth increase in terminal 
dividend since 1954. It was made with approval of connpetent actuarial auth- 
orities after review of the Association's earnings and general financial con- 
dition. 

The current year has been one of outstanding achievement. In August 
the Association attained its goal of $200,000,000 protection in force and assets 
now exceed $43,000,000. The Association is in a stronger financial position 
than ever in the past to accomplish its purpose of providing the greatest amount 
of insurance at the least possible cost. 

Officers wishing additional information should address their inquiries 
to the Navy Mutual Aid Association, Navy Department, Washington 25, D. C. 

:{( 9$: ^ :{! 3{( :^ 



Medical News Letter, Vol. 34, No. 12 17 



A Letter to the Surgeon General 



On the occasion of his recent departure from a visit to the United States, 
Major General P.V. Somer, The Surgeon General of the Finnish Defense 
Forces, addressed the following letter to Rear Admiral B. W. Hogan, Surgeon 
General of the United States Navy: 



"Dear Admiral: 

My pleasant duty before my departure from the 
United States is to express my deeply felt gratitude to you 
and the members of the Navy's medical staff for the kind- 
ness, help, and interest manifested to me during my tour. 

The visits to the Medical Center of the United 
States Navy in Bethesda, to the Naval Hospital of San Diego, 
and to the Underwater Dennolition Unit have greatly added 
to nay knowledge and greatly increased my perspectives 
of the field of medicine during tinaes of peace as well as 
times of war. The courtesy and kindness of everyone I 
encountered on my tour have made it a memorable one. 

During nay visits, I noticed the high standards 
of all Navy medical installations and, also, the devotion 
with which everyone works in his individual tasks. 

Please accept. Admiral, the assurance of my 
deepest gratitude and best wishes for your personal health 
and success in each task. 

Very sincerely yours, 

/s/ 
P. V, Somer" 



18 Medical News Letter, Vol. 34, No. 12 



Military Immunization - New Film Release 

Two new Navy films on military immunization which reflect current 
triservice regulations and practices are now being distributed. They are: 
MN-8568-a, "Military Immunization - General Procedures, " and MN-8568-b, 
"Military Immunization - Smallpox Vaccination. " 

The first, on general procedures, shows all the carefully planned steps 
in a system by which a small team of medical personnel can immunize large 
groups of men quickly, but with no compromise of the highest standards of 
medical practice. The procedure is adaptable to any mass -immunization 
requirement, such as a roundup where innmiinization of all personnel on a 
base are brought up to date, an operation where injections are given to an 
entire ship's company with minimum interruption of ship's work, or the fast 
and safe immunization of hundreds of men at a recruit training center. Em- 
phasis is on the detailed planning and organization by the medical officer in 
charge, which is essential to both speed and smoothness of the procedure and 
safety of the patients. This film, 23 minutes in length, is in black and white. 

The second film shows proper procedures for smallpox vaccination and 
for observing and recording its various effects. Particular instruction is 
given in storage and handling of vaccine, cleansing the site of vaccination 
with soap and water and then acetone, use of multiple-pressure technique, 
and recognition of primary, immediate, and accelerated reactions. Use of 
slow-motion photography in demonstration of multiple pressure, and of 
extremely large close-ups of several typical reactions especially recommend 
this film as an aid to training of medical personnel who are responsible for 
immunization either of individuals or of large numbers of men. The film is 
12 minutes long and is in color. 

Prints of these films are being distributed to the Navy's Preventive 
Medicine Units in addition to the standard distribution list of hospitals and 
Naval District libraries. If prints are not available through the usual source, 
address inquiry to the Film Distribution Unit, Training Division, Bureau of 
Naval Personnel, Department of the Navy, Washington 25, D. C. 

****** 

Directives 

From time to time, attention is invited to directives that are of sig- 
nificant general concern. For economy of space, they are described only 
by number, date, subject, and statement of purpose. Directives may be 
studied in detail from the complete copy which usiially may be obtained at 
the Administrative or Personnel Office. When not available locally, copies 
of BuMed Directives may be obtained from Navy Supply Center, Oakland, 
Calif. , or Norfolk, Va. , or Naval Weapons Plant, Washington, D. C. 



Medical News Letter, Vol. 34, No. IZ 19 



BUMED INSTRUCTION 5100. IB 24 November 1959 

Subj: Code for Use of Flammable Anesthetics (Safe Practice for Hospital 
Operating Rooms) 

This instruction directs attention to ignition hazards of flaminable mixtures 
of combustible anesthetic agents, and to measures applicable in. reduction 
and control of these hazards. 

BUMED INSTRUCTION 6320. 22A 24 November 1959 

Subj: Dependents' Medical Care in Civilian Facilities in Areas Other than 
United States and Puerto Rico; payment of charges for 

This instruction provides procedures for payment of authorized medical care 
for spouses and children of active duty Navy and Marine Corps personnel 
from civilian physicians and in civilian medical facilities in areas other than 
the United States and Puerto Rico; and supersedes BuMed Instruction 6320. 22. 

sic ijc :^ i{c :{: s^ 

Recent Research Reports 

Naval Medical Research Unit No. 3 (Cairo, Egypt), Navy #540 c/o FPO, 
N. Y.. N. Y . 

1. The Gerbils of Egypt. NM 52 08 03.0.05, December 1958. 

2. Sexual Dimorphism in Coloration in the Viper Cerastes Vipera L . 
NM 52 08 03.7.03, December 1958. 

3. The Mustelids of Egypt. NM 52 08 03.7.06, December 1958. 

4. The Biochemistry of Henna. NM 72 01 03.5.2, August 1959. 

5. Cardiopulmonary Studies in Schistosomiasis - Pulmonary Function in the 
Normal Egyptian Males. NM 72 01 03.4.06, September 1959. 

Naval Dental Research Facility, U.S. Naval Training Center, Great Lakes, 111 . 
1. Rate of Flow of Parotid Secretion. NM 75 03 27, October 1959. 

Naval Medical Research Unit No. 4, Naval Training Center, Great Lakes, 111 . 
1. Intracutaneous and Subcutaneous Asian Influenza Virus Vaccination Studies. 
NM 52 05 04. 5. 1, 26 January 1959. 

Aviation Medical Acceleration Laboratory, Naval Air Development Center , 

Johnsville, Pa . 
1. A Physiological End Point for Study of the Tolerance of Small Mammals to 

High Acceleration Stress. NM 00 02 12.15, Report No. 1. 17 June 1959. 



20 Medical News Letter, Vol, 34, No. 12 



2. A Stable Continuously Recording Electrode System for the Determination 
of Oxygen Dissolved in Protein Solutions. NM 1101 12. 7, Report No. 7 
20 July 1959. 

3. Relationships between Semicircular Canal Function and Otolith Organ 
Function. NM 17 01 12. 1, Report No. 8, 8 September 1959. 

4. Production of Pain and Thermal Burns in Skin Areas Previously Exposed 
to Ultraviolet Radiation. NM 19 01 12. 1, Report No. 19, 21 September 
1959. 

Naval Medical Field Research Laboratory, Marine Barracks, Camp Lejemie , 
N. C. 

1. Treatment of Severe Thermal Burns with Digoxin and Intravenous Flviids. 
NM 61 01 09. 1. 11, September 1959. 

2. A Breath-Holding Test; A Preliminary Investigation of Its Psychometric 
Usefulness. NM 18 01 09. 1.2, October 1959. 

Naval Medical Research Laboratory, U.S. Naval Submarine Base, New 
London, Conn . 

1. Comparison of Scotopic, Mesopic, and Photopic Spectral Sensitivity 
Curves. Report No. 295, NM 22 01 20. 01. 04, 10 March 1958. 

2. Relationship between Stimulus Size and Threshold Intensity in the Fovea 
Measured at Four Exposure Times. Report No. 297. NM 22 01 20.01.06, 
8 June 1958. 

3. Brief Tone Audiometry - Temporal Integration in the Hypacusic. Report 
No. 298. NM 22 01 20.03.03, 15 June 1958. 

4. Relationships between Submarine School Performance and Scores on the 
Navy Thematic Apperception Test. Report No. 301. NM 23 02 20. 01.04, 
1 October 1958. 

5. Exploratory Study of the Efficacy of Dioctyl Sodium Sulfo succinate (Colace) 
in the Control of Constipation of Submariners during a Prolonged Snorkel 
Cruise. Report No. 305. NM 24 01 20. 04. 04, 15 December 1958. 

6. Standardization of a Scotopic Sensitivity Test. Report No. 308. NM 23 01 
20.04.03, 17 March 1959. 

7. Identification of Signal Lights: I. Blue, Green, White, and Purple. 

II. Elimination of the Purple Categroy. Report No. 310. NM 22 02 20.03.01, 
22 May 1959. 

8. Survey of the Lighting Installation in the USS TUSK (SS-426). Memorandum 
Report No. 59-3. NM 22 02 20.01.05, 2 June 1959. 

9. Studies of Basic Cochlear Physiology and the Energy Metabolism of the 
Cochlear Response in the Cat. Report No. 311. NM 24 01 20. 02. 02, 
16 June 1959. 

10. Combined Ventilatory and Breath-Holding Evaluation of Sensitivity to 
Respiratory Gases. Report No. 315. NM 24 02 20.01.02, 20 July 1959. 



Medical News Letter, Vol. 34, No. 12 21 



11. Predicting Submarine School Attrition fronn the Minnesota Multiphasic 
Personality Inventory. Report No. 313. NM 23 02 20, 1. 06, 20 August 
1959. 

12. Effect of Test Stimulus on the Measurement of Dark Adaptation. Report 
No. 318. NM 22 01 20.01.08, 8 September 1959. 

Naval Mine Defense Laboratory, Panama City, Fla . 

1. The Explosive Decompression Component of Air Blast. NM 64 01 23, 
June 1959. 

Naval School of Aviation Medicine, NAS, Pensacola, Fla . 

1. Listener Reception -The Effects of: Part I. Diotic and Dichotic Peak 
Clipping. Part II. Reintroducing Selective Filtering at Various Interrup- 
tion Rates. Part III. Specified Amounts of Peak Clipping, Report No. 82, 
Subtask No. 1. NM 18 02 99, 5 January 1959. 

2. Idiopathic Orthostatic Hypotension and Its Relationship to Positive G 
Tolerance. Report No. 13, Subtask No. 1. NM 11 01 11, 21 May 1959. 

3. Time Required for Detection of Stationary and Moving Objects as a Function 
of Size in Homogeneous and Partially Structured Visual Fields. Report No. 15 
NM 17 10 99, 26 May 1959. 

4. Evaluation of Certain Visual and Related Tests: VI, Special Phoria Tests, 
Report No. 7. Subtask No. 6. NM 14 01 11, 7 July 1959. 

U.S. Navy Medical Research Unit No. 2 (Taipei, Taiwan), APO 63, San 
Francisco, Calif . 

1. Treatment of Cholera. NM 52 11 02.3.4, 1 August 1959. 

2. Trematode Parasites of Vertebrates of East Pakistan. NM 52 15 02. 1.6, 
21 August 1959. 

3. Adenovirus Infections in Chinese Army Recruits on Taiwan. NM 52 05 02 
.10.3, 12 October 1959. 

(To be continued in an early issue) 

:{c 9jc :jc 4^ sjE :^ 

From the Note Book 

Cystic Fibrosis . Although estinnates of the number of patients discharged 
from hospitals with a diagnosis of cystic fibrosis are probably far short of 
the prevalence of the disease in the general population, the fact that in one 
year 2,500 persons were hospitalized and that one out of every 6 or 7 was dis- 
charged by death affords a striking picture of the seriousness of this disease. 
(M.G. Sirken, Ph, D. , et al. Pub. Health Rep. , September 1959) 



22 Medical News Letter, Vol. 34, No. 12 



Cerebrovascular Disease - Stroke Syndrome. Considering that periodic 
evaluation of the methods of diagnosis and results of treatment is essential 
to a better understanding of the problems being faced in patients with cerebro- 
vascular disease, the authors present a review of the problem with current 
nnethods of diagnostic evaluation. {Gurdjian, E. S. , et al, J. Nerv. andMent. 
Dis. , September 1959) 

Indications for Concimon Duct Exploration . Absolute indications: palpable 
stones, jaundice, pancreatitis, x-ray evidence of stones in common duct. 
Relative indications: dilated common duct, small stones in gallbladder, 
high epigastric or subxiphoid pain, aspiration of turbid bile from common duct. 
Presence of two or more relative indications usually indicate exploration. 
(A. Smith, M. Wilhelm, Am, J. Surg., October 1959) 

Erythropoietic Principle of Kidney . By means of experiments in mice, the 
author has demonstrated that the kidney produces a principle of importance 
in erythropoiesis differing from erythropoietin. Observations incident to 
experiments indicated that erythropoietin is produced in the liver. 
(Sverre Osnes, University of Oslo, Brit. M. J. , October 1959) 

Giant Hypertrophic Gastritis . Reviewing the literature and discussing six 
cases of their own, the authors conclude that this condition which presents 
a clinical picture sometimes similar to peptic ulcer disease, is not as rare 
as frequently considered. Clinical and laboratory studies usually result in 
a diagnosis of malignancy with gastric biopsy required to establish the cor- 
rect pathologic condition. (J. Moran, J. Beal, Am, J. Surg, , October 1959) 

Fibrocystic Disease of Breast and Carcinomia . Reviewing 876 patients with 
mammary gland lesions, the incidence of coexisting fibrocystic disease and 
carcinonaa was found to be 3. 1% which was not considered supportive evidence 
for the theory that fibrocystic disease is precancerous. (J. Hodge, et al, 
A.M. A, Arch. Surg., October 1959) 

Latex Test . Applying the latex test to serunn and to an euglobulin fraction 
of the serunm of some healthy subjects, some patients with various rheumatic 
disorders, and some with nonrheumatic diseases, the author concludes that 
the test appears to be at least as accurate in the diagnosis of rheumatoid 
arthritis as the sheep cell techniques and has some technical advantages. 
(M.R. Jeffrey, J. Lab. & Clin. Med., October 1959) 

Mediastinoscopy . At the Clinic of Thoracic Surgery, Stockholm, Sweden, 
the author sought a procedure that was simpler for the patient than thoracotomy 
to determine the extent to which mediastinal disease might be caused by malig- 
nancy. The technique of mediastinoscopy devised and performed in over 100 



Medical News Letter, Vol. 34, No. 12 23 



cases without complication is presented. (Eric Carlens, Dis. Chest, 
October 1959) 

Abd o minal Crisis Pain . When short term cyclic episodes of constant and 
widespread abdominal pain are not influenced by eating, defacating, or expel- 
ling flatus, it is probably of central origin. A hysterical element is some- 
times observed in this syndrome which also may be a migraine or epilepsy 
component. (Walter Alvarez, Postgrad. Med. , October 1959) 

Daytime Sedatives . Evaluating many sedatives commonly employed for day- 
time sedation as well as nocturnal hypnosis, the findings of the authors indi- 
cated that butabarbital sodium provided the highest rating of therapeutic 
index. (R. Batterman, et al. , Postgrad. Med. , October 1959) 

Rheumatoid Arthritis and Heart Disease . A case report and brief review of 
the literature of concurrence of rheunnatoid spondylitis and heart disease is 
presented, adding to the growing list of such reported occurrences. The 
common triad is: (1) rheumatoid ankylosing spondylitis, (2) inflammation of 
the aortic valve and scarring of the pericardium, and (3) conduction defect 
(atrio-ventricular nodal or bundle branch block, or both). (G. Burch, 
G. Malaret, Am. J. Med. Sci. , October 1959) 

Malignant Melanoma . Isolation and perfusion with cancericidal drugs in the 
experience of the authors has yielded encouraging results in treatment of 
malignant melanoma of the extremities. This technique allows less radical 
surgery than is customarily considered mandatory. (R. Ryan, et al, Plast. 
and Reconstruct. Surg. , October 1959) 

Prothrombin Time. A method is described for estimation of the prothrombin 
time of capillary blood obtained by finger puncture with results being available 
within 2 minutes. This procedure is considered to be particularly suitable 
and desirable for management of out-patients on continued anticoagulant ther- 
apy, (R. MacMillan, D. Watt, Am. J, Med. Sci, , October 1959) 

Myocardial Infarction in Portal Cirrhosis . Reviewing autopsies for a 20 -year 
period, the authors presented results that indicate that individuals with portal 
cirrhosis suffer fatal coronary occlusion with myocardial infarction less fre- 
quently than do noncirrhotics. Factors involved in this coincidence are dis- 
cussed. (W. Grant, et al, Ann. Int. Med, , October 1959) 

Pulmonary Blastomycosis. A series of 35 patients with blastomycosis were 
reviewed with particular attention to 27 individuals who had pulmonary in- 
volvement. Clinical features of this disease are discussed with case histories 
representing various aspects of the problem, (R. Abernathy, Ann. Int. Med. , 
October 1959) 



24 



Medical News Letter, tQl. 34, No. 12 



DEIMTAL 




SECTIOIV 



Twelfth Anniversary of Dental Rating 

Following is an open letter from RADM C, W, Schantz, Assistant Chief of 
the Bureau of Medicine and Surgery (Dentistry) and Chief of Dental Division, 
to all Dental Technicians upon the occasion of the 12th anniversary of estab- 
lishment of the Rating Group, XI, Dental. 

"It is a pleasure for me as Assistant Chief of the Bureau of Medicine 
and Surgery (Dentistry) and Chief of the Dental Division, to extend hearty 
congratulations and best wishes to every Dental Technician on the twelfth 
anniversary of the establishment of the Dental Rating. 

The rating Group XI, Dental, was established in December 1947 by 
the Chief of Naval Personnel, with the approval of the Secretary of the 
Navy. In April 1948, the ratings of Hospital Corpsmen who were already 
qualified as Dental Technicians were changed to the Dental Rating as Dental 
Apprentice, Dentalman, or Dental Technician. At the present time approx- 
imately 2, 750 DentalTechnicians are serving in more than 400 Navy and 
Marine Corps activities, afloat and ashore. 

Through their skillful and intelligent performance of duty, Dental Tech- 
nicians contribute greatly to the high standards of dental care provided by 
officers of the U.S. Navy Dental Corps. In supporting the actions of units 
to which attached, Dental Technicians have displayed heroism and excep- 
tional devotion to duty. This was particularly true during the Korean con- 
flict when twenty Dental Technicians, serving with the First Marine Division, 
won awards which included the Navy Cross, Silver Star, and Bronze Star. 

I am happy to report at the time of this anniversary that reenlistment 
rates are increasing and that opportunity for advancement is improving. 
On behalf of the Navy Dental Corps, I say to each Dental Technician, 

'Well Done!' " 



****** 



Medical News Letter, Vol. 34, No. it 25 



Reduced Lactobacilli Count Due to 
Elimination of Caries 

Five male persons — average age 24 years — were selected for this study. 
Each subject had at least ten carious lesions and exhibited an extremely high 
salivary lactobacillus count. For each individual, two pre -treatment lacto- 
bacilli counts were taken (tomato juice agar) on successive days. The average 
count for the group was 98,000 colonies /ml. of saliva. All carious lesions 
were then eliminated and the cavities filled with amalgam and silicate cement, 
Lactobacilli counts were subsequently made on the week following and at 
monthly intervals for 14 months. Three of five individuals exhibited zero 
counts throughout the 14-month postoperative period. The remaining two sub- 
jects attained counts below 2, 000 within the first month and frequently exhibited 
zero counts during the period of observation. All carious lesions of an addition- 
al ten cases with rampant caries, average age 18 years, were filled with zinc 
oxide and eugenol cement. These persons exhibited an average lactobacillus 
count of 132,000 for three successive pre-treatment counts. Post-treatment 
counts were made at weekly intervals for 4 weeks. Seven of the ten subjects 
showed a zero count during the first postoperative week and continued at this 
level during the 4-week period. The remaining three consistently exhibited 
high counts for 4 weeks, but in these cases newly formed carious lesions 
occurred and decalcified areas were observed. These findings confirm a 
previous study wherein precipitous drops in lactobacilli counts occurred in 
39 individuals after a full mouth rehabilitation. (I. L. Shklair, H. R. Englander, 
K. C. Hoerman, Dental Research Facility, NTC, Great Lakes, 111. : Abstract, 
35th General Meeting, International Association for Dental Research, March 195 7) 

****** 
The Nature of Discipline 

Discipline is not synonymous solely with punishment, as many people 
believe. The word comes from the Latin noun disciplina which means 
'teaching. " That is the chief objective of discipline within the Dental Corps, 
for a well -disciplined Naval unit responds automatically and without panic 
in an emergency. 

Discipline is defined as "control gained by enforcing obedience or order, 
as in a school or army; hence, orderly conduct; as, troops noted for their 
discipline. " Again, discipline can be defined as "training or a course of train- 
ing that corrects, molds, strengthens, or perfects. " The Dental officer has 
no choice: He is responsible to higher authority for the conduct and appearance 
of his subordinates; in other words, he is responsible for their discipline. 

The purpose of discipline is to coordinate human actions under leadership 
for attainment of a common goal. Effective discipline demands that each indi- 
vidual fit into the over- all organization. 



26 Medical News Letter, Vol. 34, No. 12 



Human experience has proved the necessity of discipline whenever people 
work together to realize any aim. The need for a set of rules and for adherence 
to rules is demonstrated not only by executive orders and by laws recorded in 
writing by legislatures, but by unwritten laws, sanctioned by customs and usage, 
called conventions. Each member of the group profits by belonging; in turn, 
each member must conform to rules governing relations between individuals 
that have been set up by duly constituted authority. 

Effects of discipline are encountered everywhere. A citizen cannot go 
from his hom^e to work without traveling over streets built by means of tax 
moneys levied upon him and others, controlled by traffic lights aimed to keep 
traffic moving safely, and policed by his agents. The law-abiding person con- 
tributes to, and gains from, these and other orderly arrangements for group 
living. He must likewise learn and accept the laws of nature. The well- 
adjusted man, in the Navy or out, is he who has a healthy concept of discipline. 

Following a recent study, ADM Arleigh Burke USN stated: "A well- 
disciplined organization is one whose members work with enthusiasnn, willing- 
ness, and zest, both as individuals and as a group, to fulfill the mission of 
the organization with expectations of success. " The signs of discipline are a 
smart salute, proper wearing of the uniform, and prompt and efficient action 
in an emergency and in battle. 

Several theories are offered for securing and maintaining discipline; 
preventive theory, based on an extensive planned welfare. and recreation 
prograna; punishment theory, based upon the fear of the consequences of vio- 
lating rules and regulations; and the reward theory. 

Men's actions are controlled largely by one of two motives: fear of 
punishment or hope of reward. Although hope of reward is the more desirable 
stiniulus, having as its results greater efficiency and harmony, fear of punish- 
ment cannot be entirely dispensed with. Punishment cannot be entirely dis- 
pensed with because in certain cases it can be used to obtain immediate results. 
The Navy cannot permit a man to become a habitual offender. Punishment, 
judiciously awarded, can salvage a man; but punishment, unjustly or erratically 
administered, can destroy a man. Before taking any disciplinary action it is 
wise for the Dental officer to verify all facts, to completely evaluate the sit- 
uation. Such offenses as gross disrespect for authority, willful disobedience, 
and sleeping on watch must be punished swiftly, impartially, and sternly. 
Because of the effect on other men, it is particularly important that penalties 
follow soon after the offense. 

It should be remennbered that men kept in constant fear of arbitrary 
punishment lose the initiative and resourcefxilness necessary in a modern 
navy. Some primitive leaders (and a few modern ones with primitive tenden- 
cies) have practiced the custom of having a follower liquidated occasionally 
just to keep the remainder in line. This philosophy of keeping men in line 
through fear is currently in bad repute; there is no place for it in an organiza- 
tion requiring the good will and high morale of its personnel. Men should be 



Medical News Letter, Vol. 34, No. 12 27 



aware of the punishment that will surely be administered if they transgress, 
but should be so confident of their training and should take such pride in their 
skills and in the good name of their unit that they need not feel the pressure 
of fear. 

To build up a high state of positive discipline is to provide an environ- 
ment for excellence in performance; good work in turn produces high morale. 
On the other hand, negative discipline can be a strong factor — but it naust be 
used with great care. 

Continuous Training Program 

A short postgraduate course in Periodontics will be presented at the 
U.S. Naval Dental School, NNMC, Bethesda, Md. , on 29 February through 
4 March I960, and 2 May through 6 May I960. This course will consist of 
lectures, discussions, and clinical demonstrations. Emphasis will be placed 
on a practical approach to eliminating the periodontal pocket, tissue changes 
in occlusal trauma, and systemic aspects of periodontal disease. Surgical 
procedures will be reviewed. 

CDR P. C. Alexander DC USN, Diplomate, American Board of Perio- 
dontology, will be instructor for the course. Quotas have been assigned to 
the following Naval Districts and Commands: 1st, 3rd, 5th, 6th, 9th, PRNC, 
SRNC, and CNATRA. 

:4e 4 3^ ^ 3^ 4: 

Newly Standardized Dental Item 

It has been determined through use that FSN 6520-531-0500, although 

cataloged as suitable for fabrication of both maxillary and mandibular dentures, 

is suitable only for maxillary dentures. Identification for this item is currently 

being modified to reflect its correct use. The following new item is available 

for use in fabricating mandibular dentures: 

Unit of 

Stock No . Item Identification Issue Unit Price 

6520-559-9935 FLASK, DENTURE, Ejector Type: Each $6.50 

(Hanau Type). For use in proces- 
sing of lower cases. For "C" clamp 
requisition 6520-299-8025; for press 
requisition 6520-515-5150; for ejector 
requisition 6520-531-0600; for clamp 
and ejector requisition 6520-550-2900. 

9|c :)! :4( sjc ifc :{: 



28 Medical News Letter, Vol. 34, No. 12 



Professional Meetings 

Gold Foil Study Club . A gold foil study club, known as "The Great Lakes 
Gold Foil Seminar, " has been organized at the U.S. Naval Training Center, 
Great Lakes, 111. The club with twenty charter members will meet semi- 
monthly. Annong subjects to be discussed will be methods of improving opera- 
tive proficiency through improved utilization of dental assistants. 

LT Arthur G. McDonnell DC USNR was elected President of the club. 

Portsmouth Dental Society . Dental officers of the Norfolk Naval Shipyard, 
Portsmouth, Va. , recently acted as hosts to civilian dentists of the Ports- 
mouth Dental Society. The naeeting was held at the Commissioned Officers 
Mess (Open) in the Shipyard. A "Welcome Aboard" was presented by the 
Senior Dental Officer, CAPT F.I. Gonzales, Jr., DC USN, and was followed 
by a short business meeting of the society. The group then adjourned to the 
Shipyard Dental Clinic where a program of specialized dentistry was presented 
by CAPT A. L, Teitel DC USN, CDR S. T. Elder DC USN, and LCDR W.J.Jasper 
DC USN. 

British Dental Association . CDR E. R. Bernhausen DC USN recently presented 
a paper, "Partial Denture Planning, " before the British Dental Association 
(East of Scotland Branch) in Edinburgh, Scotland. CDR Bernhausen emphasized 
the importance of proper denture design. 

Tic iji >tf :^ :^ :i^ 

Obit ua r y 

CAPT John R. Mclntyre DC USN (Ret) died on 2 November 1959. CAPT 
Mclntyre was born in Washington, D. C. , and graduated from Georgetown 
University in June 1928. He reported for his first tour of active duty to the 
U.S. Naval Training Station, Newport, R. I. , in November 1941. Among the 
many ships and stations on board which CAPT Mclntyre served were: USS 
KENMORE, USS WRIGHT, USS SAN CLEMENTE, and USS VALLEY FORGE. 
In December 1955, while on duty at the Marine Corps Air Station, El Toro, 
Calif. , CAPT Mclntyre was placed on the Temporary Disability Retired List 
of the Navy. 



Policy 

The U.S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 



Medical News Letter, Vol. 34, No. 12 29 



items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such information. The items used are neither intended to be, 
nor are they, susceptible to use by any officer as a substitute for any item 
or article in its original form. All readers of the News Letter are urged 
to obtain the original of those items of particular interest to the individual. 

* * jjs * * * 




RESERVE ^^^^ SECTIOIM 



Criteria for Earning Promotion Point Credits 

Active Duty for Training, Appropriate Duty, Drill Participation 

1. Twelve promotion points are creditable for each fiscal year since 
30 June 1949 in which participation in present grade in the Naval Reserve was 
at the following minimtim levels: 

a. Fiscal Year 1961 and Subsequently (Effective 1 July I960) . Points 
are creditable for meeting the participation reqviirement of either subparagraph 
(1) or (2) below: 

(1) Completion of 14 days' active duty or active duty for training, or 

(2) Attendance at 75% of the drills authorized for the unit or units 
in which enrolled; or completion of 75% of the periods of appropriate duty auth- 
orized, but in no case less than 18 drills or periods of appropriate duty as 
appropriate. 

(a) Drills attended as an instructor in a Naval Reserve Officer 
School are included. Drills attended.a.s a student in Naval Reserve Officer 
School are not included. 

(b) The number of drills authorized or periods of appropriate 
duty authorized are those numbers approved by the cognizant commandant or 
overseas commander and are within the limits set forth in the tables of organ- 
ization of the Naval Reserve. 

(c) The number of drills attended is the total number reported 
on Quarterly Naval Reserve Drill Reports (NavPers 1259}. 

(d) The number of periods of appropriate duty completed is 
the total num.ber reported to, and approved by, the commandant. 



30 Medical News Letter, Vol, 34, No. 12 

(e) In the case of a drilling unit, an officer's percentage of 
attendance is determined by dividing the total number of drills attended by the 
total number of drills authorized. If an officer is enrolled. in more than one 
unit during a year, the divisor in this computation is the number of drills 
authorized for the unit having the least number of drills, 

(f) In the case of appropriate duty, an officer's percentage 
of attendance is determined by dividing the total number of appropriate duty 
periods completed by the total number authorized. 

(g) In the case of dual status in which an officer participates 
both in a drilling unit and under appropriate duty orders, the drills attended 
and drills authorized in the drilling unit govern, and computation is in accor- 
dance with subparagraph la{2) (e) above. 

b. Fiscal Years 1958 and 1959 (1 July 1957 through 30 June I960 ). 
Minimum participation requirements were the same as in subparagraph la 
above, except for the following: 

(1) Appropriate duty is considered in the same category as 
active duty or active duty for training. 

(2) The minimum number of periods is 14 instead of 18. 

c. Fiscal Years 1956 and 1957 (1 July 1955 through 30 June 1957) . 
Minimum participation requirements were the same as in subparagraph la 
above, except for the following: 

(1) The minimum number of drills was 12 instead of 18. 

(2) Drills attended as either an instructor or a student in a 
Naval Reserve Officer School course were included in drill attendance. 

(3) The provisions of subparagraph lb apply. 

d. Fiscal Years 1950 through 1955 (1 July 1949 through 30 June 1955) . 
Completion of the requirements for a year of satisfactory Federal service 

through accrual of 50 retirement points, provided that at least 12 of the retire- 
ment points were earned by active duty, active duty for training, drills, or 
appropriate duty. For officers having anniversary years other than the fiscal 
year, the 12 points in fiscal year 1955 were creditable for the portion of a year 
between anniversary date and 30 June 1955, provided that in that period at least 
50 retirement points were accrued, at least 12 of which were earned by active 
duty, active duty for training, drills, or appropriate duty. 

College Courses and Residency Training 

1. Officers enrolled in a resident course of an accredited college or 
university, or Medical and Dental officers enrolled in a course of residency 
training approved by the Chief of the Bureau of Medicine and Surgery will, 
upon their application, be credited with one promotion point for each semester 
hour or equivalent thereof satisfactorily completed. Not more than 12 promo- 
tion points will be credited for 1 fiscal year. 

a. To be creditable, courses must have been conapleted in present 
grade since 1 July 1950. For courses completed prior to 1 July 1957, promotion 



Medical News Letter, Vol. 34, No. 12 31 



points are creditable as of 1 July 1957. Courses completed in subsequent 
fiscal years will be creditable as of 30 June of the fiscal year in which com- 
pleted. 

b. "Accredited college or university" is defined as any college or 
university listed in the official publication of the Office of Education, Depart- 
ment of Health, Education, and Welfare, "Accredited Higher Institutions. " 
The currently effective publication is "Office of Education Bulletin 1957, 
No. 1, Accredited Higher Institutions, 1956. " 

c- Courses completed at foreign universities are not creditable 
unless they have been accredited by an American college or university in 
terms of semester or quarter hours. The burden of translation of foreign 
credits into acceptable semester hours is placed on the individual officer. 
Translation can be effected by the registrar of an accredited college or univ- 
ersity, or by the U. S. Office of Education. 

d. Credits granted in tertns of quarter hours will be converted to 
sennester hours by multiplying by two-thirds. Any system of credits that is 
not readily transferable to semester hours will be referred to the Chief of 
Naval Personnel for adjudication. 

e. Requests for promotion credit for college or university courses 
will be made by the individual officer to the Officer in Charge, Reserve Officer 
Recording Activity, forwarded via the command holding the officer's service 
record. The request must be accompanied by a transcript of credits from the 
college or university. The command holding the officer's service record will 
evaluate the transcript and, by endorsement, certify the nunnber of promotion 
points (not to exceed IZ) assigned for each fiscal year. The transcript will be 
retained by the command holding the officer's service record. In case of doubt 
as to proper credit, the command holding the officer's service record will for- 
ward the request to the Chief of Naval Personnel. 

f. Requests for promotion credit by doctors or dentists who have 
completed residency training will be made by the individual officer to the Officer 
in Charge, Reserve Officer Recording Activity, forwarded via the Chief, Bureau 
of Medicine and Surgery. The request must be accompanied by a certification 
from the institution in which training was taken as to the type of residency train- 
ing and the inclusive periods in which enrolled. The Chief, Bureau of Medicine 
and Surgery, will evaluate the training and, by endorsement, certify the num- 
ber of promotion points (not to exceed 12) assigned for each fiscal year. 

For additional information concerning promotion point credit consult 
BuPers Instruction 1416. 4C. 



Continuation on Mailing List. Attention of Reservists — not on active duty — is 
directed to requirement for returning the notice for continuation of the Medical 
News Letter, Please return notice on pages 39 and 40 if the News Letter is 
desired, making sure the form is filled in completely and legibly. 



32 Medical News Letter, Vol. 34, No. 12 

AVIATION MEDICINE DIVISION 




Flight Fatigue 

Following is a report by LT R. L. Brisbin MC USNR, Airborne Early Warning 
Squadron TWELVE, Flight Surgeon for flight crew members in AEWWINGPAC 
to inform them of areas where they may be able to assist in lessening the prob- 
lem of flight fatigue. 

1. Introduction 

a. Fatigue, literally meaning to "waste away, " is a universal experi- 
ence among human beings to some degree or another. Because of its 
universal nature and its usual lack of serious consequences, except in ex- 
treme form, we ordinarily do not pay much attention to it; however, even 
in small amounts, it is of paramount importance to aviation safety and is 
probably one of the most critical problems in modern aviation medicine. 
One of the main reasons for this is that while we have made great strides 
in developing aircraft with increasing long range, higher performance, and 
greater technical complexity, we have not paralleled these strides in the 
understanding of our human machines. So we must examine closely what 

is known about human fatigue, attennpt to apply it to our own operation, 
and then actively prevent it wherever and whenever possible. 

b. Fatigue means many things to many people. To the physiologist 
it may mean the failure of a tissue to respond after repeated stimulation; 
to the metallurgist or engineer it may mean the failure of metal in a struc- 
tural member or moving part following long use (or abuse). To us in 
aviation it may be best defined as; a stress response, primarily dependent 
only on the sheer duration of an activity, augmented by physical or purely 
psychic and emotional stresses . There are three major types of human 
fatigue with which we are concerned: physical fatigue, chronic fatigue, 
and skill or static fatigue. While I shall discuss these separately at first, 

I wish to emphasize at the outset that they are all interrelated and are 
found usually in connbination rather than singly in a given individual in 
flight. I further wish to emphasize that the presence of any one of them 
may hasten the appearance of the others. 

2. Pure Types of Fatigue 

a. Physical fatigue is that healthy, normal, muscular, and mental 
weariness following strenuous exercise or excitement. It is largely 



Medical News Letter, Vol. 34, No. 12 33 



physiologic in nature with relatively little psychologic component. It usually 
produces stimulation of the appetite and is quite conducive to relaxation. 
It also serves ordinarily as a warning sign that physical exertion should 
be discontinued so that body energy reserves may be restored. It is com- 
pletely relieved by normal sleep, muscular rest, and freedonn from excite- 
ment. 

b. Chronic cunn^ulative fatigue is mainly psychologic in nature. It results 
from the continuous strain of adjusting to stressful occupational dennands, 
often augmented by fears of death, maiming, of "letting the outfit down. " 

It has been shown that all men can develop this type of fatigue if the annount 
and duration of stress are sufficient. The reason that some men develop 
it (in a given operation) where others do not is because of individual differ- 
ences in psychologic background, personality development, and ability to 
adjust to stress. If not recognized and treated at its outset it may culminate 
eventually in the severe psychoneurosis known as "combat fatigue, " (actually 
a misnomer because true combat need not be involved). The predominant 
synaptoms of this type of fatigue in pure form are: (1) tense feelings; 
(2) irritability; (3) frustration; (4) lassitude; (5) loss of confidence; (6) greater 
awareness of body discomfort; (7) depression; (8) insomnia; (9) anorexia (loss 
of appetite); and (10) forgetfulness. 

c. The last pure form of fatigue which is seen is static or skill fatigue. 
It is this type of fatigue which forms the largest segment of flying fatigue 
and is also the most dangerous from the standpoint of aviation safety. It 
occurs in aviation personnel even in the presence of an outstanding physical 
condition and above average psychologic stability. Its main causes are comi- 
mon in all flying to some degree, and are; (1) boredom; (2) prolonged con- 
centration; (3) attention to details, especially when associated with respons- 
ibility; (4) physical discomfort, i. e, , sitting in one place for prolonged 
periods; (5) need for constant alertness; (6) mild hypoxia (oxygen lack); 

(7) noise; and (8) vibration. 

d. The reason why static fatigue is so dangerous is because of its insid- 
ious onset, its marked, if transient, effect on mental processes rather than 
physiologic ones, and because the subjective sensations of fatigue are the 
last to appear and warn the subject. It leads to unrecognized little mistakes, 
which all too often can turn (and have turned) into big accidents. The effect 
of static fatigue may be best sunnmed up as those of carelessness, compla- 
cency, and a progressive unconscious lowering of performance standards 
and motivation all out of proportion to any actual decreased capacity to 
perform or physiologic inadequacy. In many cases, the subject actually 
thinks he is performing better than usual. Controlled studies have shown 
the following to be the naost important examples of performance or output 
decrenment seen with static fatigue; (1) need for larger than usual stimuli 

to call forth an appropriate response; (2) errors of timing in performing 
tasks comprising more than one action; (3) overlooking of important elemients 



34 Medical News Letter, Vol. 34, No. 12 

in a given task sequence; (4) loss of accuracy and smoothness in control 
column movements leading to over controlling and jerkiness; (5) unaware- 
ness of even gross errors in heading, altitude, attitude, and increasing 
susceptibility to vertigo; (6) greater unreliability of reports of what trans- 
pired during a given tinne; and (7) inattention, or concentration of atten- 
tion to the center of vision with resultant neglect of the peripheral fields; 
a tendency to fix on one instrument rather tha^ "o scan all instruments. 

3. Flight Fatigue 

a. As stated earlier, all three pure types of fatigue are interdependent 
and combined to varying degrees in any flying situation, so that we may now 
speak of "flight fatigue" as a separate entity, its magnitudes of the three 
pure types. The occasions for the production of flight fatigue are alnr>ost 
endless and reach their peak in large multi-engined aircraft on long routine 
overwater flights, especially when flying on instruments or at night. Flight 
fatigue rarely lends itself to measurement in the field. Any physiologic 
responses or tissue impairments clearly referable to flying for long periods 
have, to the present, largely eluded detection. So most cases of flight 
fatigue, as we encounter them, will consist either of objective evidence of 
poor professional performance (including accidents) or of subjective exper- 
ience per se by the individual airman and his purely subjective complaints 
of fatigue. 

b. Now let us revert to the principle that some flight fatigue can be 
shown to exist before it is actually experienced and examine some of the 
known major determ^inants of flight fatigue and see what, if anything, we can 
do to combat them.: 

(1) Psychologic and Emotional Stress . Under this heading comes 
such things as boredom and monotony, responsibility, continued alertness 
and attention, immobility, mental activity in regard to performing one's 
duties, and fear. It is impossible for any barrier flight to be completely 
devoid of such "stresses. They are inherent occupational hazards. Many 
things can be done by the individual, however, to minimize their effects. 
For one thing, it has been shown that merely to understand the existence of 
these stresses and to be consciously on guard against their effects will go 
a long way toward reducing the fatigue that they cause. Fear or anxiety, 
especially in respect to potential emergency situations, can be eliminated 
largely by thorough preplanning and rehearsal. This serves to develop 
overlearning and increases self-confidence. The effects of prolonged 
mental activity, alertness, and concentration can be partially recuperated 
from by such devices as light reading, simple card games, et cetera, 
during off watches. Immobility, boredom, and monotony can be partially 
combatted by getting up periodically and moving about the aircraft, or even 
by turning around in one's seat, stretching, looking around, et cetera. 
Breaking up one's routine aloft by rotating between cockpit, navigation table, 
engineer's panel, and even radar scope may be qmte helpful to many pilots. 



Medical News Letter, Vol. 34, No. 12 35 



(2) Immobility . The need to guard against too much immobility 
also has its physical implications. Considerable muscular work is in- 
volved in just sitting and flying. A static type of muscle tension, espec- 
ially in the postural muscles, can be quite marked. In addition, there is 
often interference with circulation to certain groups of muscles due to 
seat pressures. This leads to muscular pains, further muscle tension, 
and so on. 

(3) Physical Discomfort . No military aircraft has ever been built, 
nor is one likely ever to be built, in which some degree of physical discom- 
fort did not exist for the crew. Our WV-2 is no exception. True, it is un- 
doubtedly less uncomfortable to fly in than other operational aircraft, but 
disconnfort still exists no matter where in the airplane one sits for long 
periods of time. While the construction of the aircraft obviously cannot be 
changed, certain other causal factors in this physical discomfort can be, 

(4) Noise and Vibration . This is a frequently overlooked cause of 
flight fatigue, perhaps because it i5 so common and we are so used to it 
(we think). It also may actually have a hypnotic effect in certain individuals 
when exposed for long periods. Little can be done to eliminate the source 
of it in an airplane in flight, but there is strong evidence that the wearing of 
ear plugs, at least when not on watch, can cut noise to where it is not nearly 
so fatiguing. Ear plugs are available and all medical officers and aviation 
medicine technician corpsmen are competent to fit them. They may be ob- 
tained by any pilot or aircrewnnan who would like to try them. 

(5) Hypoxia. This well established cause of flight fatigue, plus 
decreased night vision, increased susceptibility to vertigo, et cetera, is 
probably not too innportant in our WV-2 aircraft inasmuch as cabin altitude 
rarely gets above 3000 feet; however, even being at 3000 feet for long per- 
iods plus heavy cigarette and cigar smoking could conceivably enhance 
flight fatigue in our operation. Of course, wide variations in susceptibility 
to this mild degree of hypoxia can be expected so that insistence on the use 
of oxygen on the barrier under normal conditions probably is not warranted. 
I would recommend that pilots and flight engineers, if they experience sub- 
jective fatigue in flight, try breathing 100% oxygen for 5 to 10 nninutes out 
of each hour for whatever beneficial effect it might have. Naturally, rigid 
oxygen disiipline whenever cabin pressurization is lost should be insisted 
upon and periodically reviewed by all pilots and flight engineers especially. 

(6) In-Flight Feeding . We all know how innportant proper food intake 
is from the biologic standpoint, but other and most important values of food, 
especially in flight, are emotional and social, and we must be aware of 
these too. Improper food intake, especially when associated with the other 
determinants of fatigue, can have a markedly adverse effect on flying safety. 
This is because flying for long periods tends to deplete the body's physio- 
logic reserves, especially sugar, and these reserves must be kept intact 



36 Medical News Letter, Vol. 34, No. IZ 



for best performance to occur. From an emotional point of view, the air- 
craft environment may adversely affect the palatability of food and the 
desire for it, and may thereby create dietary dissatisfactions which lead 
to improper food intake, regardless of the nutritional and caloric adequacy 
of the food which is available. In addition, the emotional value of food is 
very important on extended flights to enhance morale, relieve tension, 
ease boredom, and counteract stress. 

(a) In general, emphasis should be placed on the serving of 
protein rich foods, such as meat, nnilk, eggs, and cheese because these 
foods create more prolonged, if more slowly developing, high levels of 
blood sugar; however, high sugar content foods, such as candy, cookies, 
and various pastries should be readily available on all flights not only 
for their alnnost universal taste appeal and because utensils are not nec- 
essary to prepare and consume them aboard the aircraft, but also be- 
cause of the rapidity with which their energy content is available — this 
constitutes the well known "sugar whip" concept. Smaller and more 
frequent meals are less likely to cause fatigue and drowsiness than large 
heavy meals. 

(7) Morale and Motivation . Morale properly belongs under the 
heading of psychologic stress, but is so important as a determinant of 
fatigue as to warrant special consideration. An airnnan's morale and* 
motivation are key factors in his resistance to fatigue. This is true both 
as regards individual morale and group morale. Morale and motivation 
are not rigid quantities which either are there or not. They can be changed 
in an individual or a group either for the better or for the worse. Where 
naotivation and morale are lacking they may be improved by clarifying goals 
and keeping personnel informed of progress toward those goals; by the use 
of various awards and privileges in return for good performance; by main- 
taining group morale at high levels by every reasonable naeans; by provid- 
ing variety and change where naonotony tends to exist, et cetera. 

(8) Dehydration . The subject of dehydration, which has been shown 
to contribute to flight fatigue and discomfort, properly belongs here. The 
usual conditions of tennperature and relative humidity to which personnel 
are exposed for long periods in our aircraft can easily lead to dehydration 
and, unfortunately, the degree of a man's thirst does not always parallel 
his fluid needs. The use of coffee alone to replace lost fluids will not work 
since coffee acts as a mild diuretic and actually will cause a negative fluid 
balance to develop. The drinking fluids taken aloft should always be readily 
accessible, widely varied, and highly acceptable, and I recommend that one 
cup of some other flxiid be consumed for every two to three cups of coffee. 
An excellent hot drink substitute for coffee is instant hot chocolate which 
can be obtained in single service packets and has the added advantage of its 
high sugar content. 



Medical News Letter, Vol. 34, No. 12 3 7 



4. Between Flight Preventive Measures 

a. To recognize and prevent fatigue which occurs in flight is only 

a halfway measure if the pilot or crewman turns to at preflight time with 
any backlog of fatigue from previous flights or from on-deck activities. 
The responsibility for preventing such a backlog is two-fold — that of the 
individual airman and that of command. 

b. The individual's job is mainly to maintain himself in the best pos- 
sible physical and mental condition with the help of his family, friends, 
and flight surgeon. Good habits should be cultivated so that meals are 
properly balanced in quality and quantity. All aviators know that they are 
supposed to eat a good breakfast, but what many barrier aviators forget 
is that breakfast for them is any meal just prior to beginning the day's 
work {i.e. barrier flying), whether this be at 0600, 1500, Z400, et cetera. 
The practice of substituting doughnuts and coffee, or a peanut butter sand- 
wich, et cetera, for a more well balanced meal prior to flying is to be con- 
demned soundly. 

c. Sleep and relaxation between flights is critical. All of us differ in 
our need for sleep, but at least 8 hours of sound refreshing sleep in each 
24 hours is probably the minimum that we need to be at peak performance. 
Even a slight reduction in the amount of sleep (e. g. 25 to 50%) can induce 
significant mental impairment without any subjective feelings or physical 
clues. Every attempt should be made to sleep or at least to nap just prior 
to going out for preflight because the longer the interval from awakening 
to starting a task, the greater the fatigue potential that exists. 

d. Moderation in the use of alcohol and tobacco is axionnatic for the 
prevention of in-flight fatigue. Impairment from the use of alcohol, again, 
is all out of proportion to how a person feels subjectively. The existing 
rule of abstinence from beer and liquor for at least 12 hours prior to 
take-off is an excellent one. It should be enforced rigidly by all plane 
commanders for themselves as well as for their crews. 

e. Since an airman's occupation is largely sedentary, he requires a 
naoderate amount of intelligently planned physical exercise for the main- 
tenance of peak physical condition and fatigue resistance; however, I 
recommend that a good night's sleep intervene between any physical 
recreation and flying lest a backlog of fatigue be taken aloft. 

5. Summary and Conclusions 

a. We have seen how, because of its very nature, barrier flying must 
always be fatiguing to some degree, but not necessarily to the point of 
hazard and inefficiency if (1) we can produce a vigorous effort at all levels 
for the prevention and elimination of those things which tend to produce a 
backlog and accumulation of fatigue; and (2) we can conduct an educational 
program directed at reducing to a minimum the deternainants and effects 
of fatigue secondary to flying per se. 



38 Medical News Letter, Vol. 34, No. 12 



b. This report has been prepared using most of the available reliaUie 
literature on the subject of flight fatigue plus many personal observations 
made during barrier flying. It is by no means complete. We have much 
to learn on the subject of flight fatigue and it is hoped that, by continuing 
observations in our own operation, plus using the observations of others 
in aviation medicine and aviation safety, we will be able to supplement 
substantially what has already been said in this report. Flight fatigue un- 
questionably represents a substantial aeromedical problem in AEWWINGPAC. 
How well we can come to understand it and to handle it will determine with- 
out a doubt our future performance record and our future safety record. 

6. References 

a. Technical Report, NAVTRADEVCEN 1339-28-2 

b. USAF Flight Surgeon's Manual (AF Manual l60-5) 

c. Naval Aviation Safety Officers Guide 

d. Journal of Aviation Medicine, Vol. 28, No, 3, June 1957 

e. Journal of Aviation Medicine, Vol. 29, No. 3, March 1958 

f. U, S. Navy Medical News Letter, Vol. 30, No. 12, 

20 December 1957 

g. U.S. Navy Medical News Letter, Vol. 31, No. 12, 

20 June 1958 
h. U.S. Naval Air Development Center Research Report 

MA-5802 
i. Armstrong: Principles and Practice of Aviation Medicine, 

Third Edition 
j. Approach, December 1958 

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Flight Physical Examinations 

Many Class 2 personnel are being ordered to specialized training, i. e. , 
naval aviation observers, aircrewmen, parachute junapers, et cetera, at 
the various training centers without a flight physical examination. This not 
only works a hardship on the medical facility at the training centers, but 
many men are found not physically qualified for training. It costs money to 
transfer a man. Remember you. pay taxes to help pay for this useless move. 
The flight surgeon should see that all candidates for Class 1 or 2 aviation, 
training receive a flight physical examination before being ordered to the 
training station. 

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Medical News Letter, Vol. 34, No. 1 1 



39 



SPECIAL NOTICE 

Existing regulations have established a fixed number of copies of each 
issue of the Medical News Letter, and require that all Bureau and office 
mailing lists be checked and circularized at least once each year in order 
to eliminate erroneous and duplicate mailings. 

It is requested that EACH RECIPIENT of the News Letter, with the 
listed exceptions, fill in and forward immediately the form appearing below 
if continuation on the distribution list is desired. Only one answer required. 

{Continued on page 40) 

(first fold) 



U.S. Navy Medical School 
National Naval Medical Center 
Bethesda 14, Maryland 
Official Business 



Postage and Fees Paid 
Navy Department 



To: Bureau of Medicine and Surgery 

Navy Department, Potomac Annex 
Washington 25, D. C. 



Attention: Code- 18 



PLEASE PRINT OR TYPE {second fold) 

Name or 

Activity 



PLEASE PRINT OR TYPE 



(last) (first) (initial) 

Active Duty ( ) 

(rank - corps - service oi civilian status) Inactive Duty ( ) 

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(city) 



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(state) 



If more than one copy of each 

issue desired, state number Signature 



(Staple, seal, or paste shut — this flap outside) 



40 



Medical News Letter, Vol. 34, No. 11 



EXCEPTIONS (reply not required) 

1. All Medical and Dental Corps officers, regular and reserve on ACTIVE 
DUTY, receiving News Letter at military address 

2. All U.S. Navy Ships and Stations 

Therefore, all others — active duty Medical and Dental Corps officers 
receiving News Letter at civilian address; Nurse Corps and Medical 
Service Corps officers; Ensign 1915 students; inactive personnel, reserve 
and retired: civilian addressees of all categories; foreign addressees ; and 
addressees of other U.S. Armed Forces — will please submit the form if 
the News Letter is desired. 

Failure to submit the form by 10 January I960 will result in automatic 
removal of name from the files. PLEASE PRINT OR TYPE. 

Comment or suggestions are invited and appreciated. 

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